Manual therapy in headache Manual therapy in headache 活水神經內科診所 謝鴻偉物理治療師 Manual therapy in headache 2009-07-18
Outline of presentation (1) Definition of CGH and TTH (2) Physical impairments and examinations of CGH and TTH 1.Forward head posture & upper crossed syndrome 2.Articular impairments 3.Muscular impairments — Myofascial dysfunction and muscular imbalance (3) Proposed mechanisms of manual therapy for treating headaches Mobilization and spinal manipulative therapy (SMT) (4) Review researches about manual therapy in headaches (5) Adverse effects of spinal manipulation (6) conclusion Manual therapy in headache 2009-07-18
(1)Definition of CGH and TTH Manual therapy in headache 2009-07-18
Definition of CGH 1.The term cervicogenic headache was first introduced by Sjaastad et al.(1983). The definition of cervicogenic headache is described as ‘‘referred pain perceived in any region of the head caused by a primary nociceptive source in the musculoskeletal tissues innervated by the cervical nerves.’’ (Alix,1999) cervical nerves.’’ (Alix,1999) 2.Sources of this pain lie in the structures innervated by the C1-C3 spinal nerves and include the : (Bogduk , 2001) ◎ upper cervical synovial joints, ligaments ◎ muscles of the sub-cranial spine ◎ discogenic (C2-C3) ◎ pain-sensitive dura matter Manual therapy in headache 2009-07-18
Definition of CGH 3. Headache due to disorders of the cervical spine is more than a century old, but the underlying mechanisms, signs, symptoms and treatment are debatable. 4. The typical cervicogenic headache is unilateral provoked by neck movement, awkward head positions or pressure on tender points in the neck. It can last hours or days, with pain tender points in the neck. It can last hours or days, with pain that is dull or piercing. 5. The most commonly accepted neurophysiological explanation is the convergence of the upper cervical roots on the nucleus caudalis of the trigeminal tract. 6. Most cases the CGH is caused by pathology in the upper cervical spine. Anesthetic blocks may be used to confirm the diagnosis and determine the source of pain in the neck. (Antonaci F, et al, 2006) Manual therapy in headache 2009-07-18
Clinical characteristics of CGH (J Am Osteopath Assoc . 2000) □ Unilateral head or face pain □ Head pain is triggered by neck without sideshift; the pain may movement, sustained or awkward neck occasionally be bilateral postures; digital pressure to the □ Pain localized to the occipital, suboccipital, C2, C3, or C4 regions or frontal,temporal or orbital regions over the greater occipital nerve; □ Moderate to severe pain intensity valsalva, cough or sneeze might also □ Intermittent attacks of pain □ Intermittent attacks of pain trigger pain trigger pain lasting hours to days, constant □ Associated signs and symptoms can pain or constant pain with be similar to typical migraine superimposed attacks of pain accompaniments including: □ Pain is generally deep and — nausea; vomiting; nonthrobbing; throbbing may — photophobia, phonophobia, dizziness; occur when migraine attacks are — others include ipsilateral blurred superimposed vision, lacrimation and conjunctival injection or ipsilateral neck, shoulder □ Restricted active and passive neck range of motion; neck stiffness or arm pain Manual therapy in headache 2009-07-18
Definition of TTH 1. Tension-type headache (TTH) is the most prevalent form of benign primary headache with a reported prevalence varying from 10% to 65%, depending on the classification, description, and severity of headache features. 2. The psychosocial impacts of TTH include disruptions of daily activities, quality of life & work and are accompanied daily activities, quality of life & work and are accompanied by the costs of these disruptions. 3. The International Headache Society (IHS) characterizes TTH as bilateral headaches of mild-to-moderate intensity that experienced with an aching, tightening, or pressing quality of pain. 4. Headaches may last from 30 minutes to 7 days, are not accompanied by nausea or vomiting, and may have photophobia or phonophobia (but not both). (Vernon H, 2009) Manual therapy in headache 2009-07-18
Definition of TTH 5. Headache frequency is classified as “episodic” ( ＜ 15 headaches per month) or “chronic” ( ＞ 15 per month). 6. Episodic TTH is by far the more prevalent category. 7. The chronic TTH patient has a higher frequency of both active and latent triggers points in the suboccipital mm. active and latent triggers points in the suboccipital mm. 8. The chronic TTH patient with active trigger points may have a greater headache intensity and frequency and forward head posture than those with latent trigger points. (Vernon H, 2009) Manual therapy in headache 2009-07-18
Prevalence Cervicogenic headache Tension-type headache General population (%) 0.4%-2.5% 3% Headache clinics (%) 15%-20% 40% Mean age 42.9 y/o Onset any age but most (all ages are affected) commonly during adolescence adolescence or young Adulthood 4x more prevalent in female 88% female and 69% male Gender (79.1% ♀ ♀ and 20.9% ♂ ♂ ) ♀ ♀ ♂ ♂ Other CGH is a common symptom Chronic TTH commonly occur after neck trauma; 54%-66% during periods of stress and of patients with whiplash- emotional upset. associated disorder Intensity Moderate to severe Mild to moderate Manual therapy in headache 2009-07-18
(2)Physical impairments and examinations of CGH and TTH examinations of CGH and TTH 1.Forward head posture & Upper crossed syndrome 2.Articular impairments 3.Muscular impairments Myofascial dysfunction and muscular imbalance Manual therapy in headache 2009-07-18
1.Forward head posture & Upper crossed syndrome & Upper crossed syndrome Manual therapy in headache 2009-07-18
Upper Crossed Syndrome • Upper crossed syndrome was originated by Vladimir Janda � the ‘‘Father of Czech rehabilitation”. • This is a typical posture produces overstress & muscle imbalance of the : ◎ thoracic kyphosis ◎ rounded shoulder ◎ flexion of the lower cervical spine (flattened normal lordosis curve) ◎ extension of upper cervical spine ◎ anterior head carriage (forward head posture) Manual therapy in headache 2009-07-18
Upper Crossed Syndrome originated by Vladimir Janda Weak Muscles (overstretched) 1.Rhomboids 2.Serratus Anterior 3.Low/Mid Trapezius 4.Deep neck flexors 4.Deep neck flexors Tight Muscles (shortened) 1.Pectoralis Major/minor 2.Levator Scapulae 3.Sternocleidomastoid 4.Upper Trapezius Manual therapy in headache 2009-07-18
Clinical assessment of FHP craniocervical angle measurement � smaller craniocervical angle indicates greater FHP. TTH (Fernandez-de-las-Penas, 2006) Mean C-C angle Healthy sub. 54.1 ° ± 6.3 ° 45.3 ° ± 7.6 ° Chronic TTH CGH (Trott,1993) Healthy sub. 49.1 ° ± 2.9 ° CGH 44.5 ° ± 5.5 ° Manual therapy in headache 2009-07-18
Forward head posture and CGH Occiput and C1/2 hyperextend with the fattened lordosis �� craniocervical angle �� Forward head posture (FHP) -- trend to develop cervicogenic headache . a. facet joints dysfunction � abnormal afferent information a. facet joints dysfunction � abnormal afferent information affecting the tonic neck reflex � encourage gradual adaptation of forward head posture. b. upper cervical extension � compression of craniocervical structures including greater & lesser occipital nerves, hance contributing to cervical headache. (Darnell,1983) Manual therapy in headache 2009-07-18
Forward head posture and TTH -- trend to develop tension-type headache : a. Simons et al.(1999) stated that postural abnormalities in the cervical spine might be responsible for the activation of myofascial trigger points in the neck muscles. of myofascial trigger points in the neck muscles. b. FHP can result in shortening of the posterior cervical extensor muscles (suboccipital, semispinalis, splenii, and upper trapezius) and active trigger points. c. chronic TTH with active MTrPs in the SCM / suboccipital / scalene showed smaller craniocervical angle than with latent MTrPs. (Fernandez-de-Penas et al, 2006 & 2007) Manual therapy in headache 2009-07-18
2.Articular impairments 1. Active screening movements 2. Passive Physiologic Intervertebral Movement tests (PPIVM) 2. Passive Physiologic Intervertebral Movement tests (PPIVM) 3. Passive Accessory Intervertebral Movement tests (PAIVM) 1. Nichoson G, Cervical Headache,JOSPT,2001;31(4):184-193 2. Shannon M et al, Articular and muscular impairments in cervicogenic headache: a case report, JOSPT, 2003;33:21-30 3. Tension-type headache and cervicogenic headache--pathophysiology, diagnosis, and management, Cesar Fernandez-de-penas et al,2009, p153-170 Manual therapy in headache 2009-07-18
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